July 2019 Optometrist Newsletter

STAAR Surgical Celebrates One Million Lens Milestone for Implantable Collamer Lens (ICL).

STAAR Surgical announced in April that more than one million Visian ICLs have been implanted globally. Currently approved versions of the ICL are available in more than 75 countries around the world to address the explosive growth of myopia and the need for distance vision correction.

“We celebrate the Visian ICL one million lens milestone with our ophthalmology partners, clinicians, and patients who are elevating the ICL to the premium and primary solution for refractive based vision correction,” said Caren Mason, President and CEO of STAAR Surgical Company. “More ICLs have been implanted since 2015 than the prior 15 years of the ICL combined. Today’s milestone represents only the beginning of our journey in raising ICL awareness and adoption to delight surgeons and their patients. The ICL, a remarkable biocompatible lens that works in harmony with a person’s natural eye, is designed to improve vision following a quick 20-30 minute procedure that many patients have described as ‘life changing.’ Through our ICL family of lenses STAAR aims to significantly increase our share of the existing four million annual refractive procedures globally, facilitate the market’s return to peak procedure volumes, and further grow the overall market with new and innovative lenses that address customer demands such as a refractive solution for presbyopia that may eliminate the need for reading glasses. Our work towards future milestones will be bolstered by strong clinical evidence, surgeon training, and ongoing operating and financial discipline.”

Patient DC, a 31 year accountant attended our clinic enquiring about visual rehabilitation for keratoconus. He had been diagnosed with keratoconus approximately 8 years prior to his initial enquiry with us, it was of interest that his mother and uncle both suffered from the condition. In the past, he had tried a number of different contact lenses systems including rigid gas permeable lenses, Kerasoft lenses and more recently a piggy back lens system. He was finding lenses very uncomfortable and problematic which is what prompted him to pay us a visit. He believed his condition was worsening in his right eye, but otherwise was fit and well.

On examination the following refraction was found:

Ocular examination showed:

Central corneal thicknesses were 434um in the right eye and 445um in the left eye. Corneal topographic examination showed bilateral early keratoconus with central 3mm keratometric readings of 45.7D in the right eye and 45.5D with cone apex powers of 51.5D and 50.8D respectively. Below are images of the patient’s corneal topography:

Treatment plan to be carried out over the space of a few years, depending on stability and healing:

1. Collagen corneal cross-linking R + L
2. Contact lens fitting whilst waiting for eyes to settle
3. Toric ICL implants R + L

After cross linking, the patient was fitted with ICD contact lenses – these are mini scleral lenses which employ a unique series of tangent zones, as opposed to curved surfaces, to create optimal fit and comfort for even the most challenging eyes.

R vault 3900 +2.50 LCZ STD, SLZ STD        6/7.5-

L vault 4000 0.00 LCZ STD, SLZ STD           6/7.5-

A couple of years later, patient returned for ICL surgery. As can be seen by the post cross-linking values, the patient’s BCVA improved from 6/12- to 6/7.5-. Although some studies have found a lack of visual improvement from the procedure [1], a growing body of recent research has found that not only did cross-linking stabilise progression of keratoconus but it resulted in “significant” improvements in visual acuity and reductions in aberrations [2]. “We conclude that the refractive outcomes were achieved by a flattening of the cone apex and a steepening of the part of the cornea symmetrically opposite the cone,” wrote Paolo Vinciguerra, M.D., Department of Ophthalmology, Istituto Clinico Humanitas, Milan, Italy, and colleagues (source: https://www.eyeworld.org/).

Post cross linking refraction:

The improved level of BCVA now makes the patient a good candidate for ICL surgery. The toric ICL is conventionally indicated for the correction of myopia in adults aged 21-40 years with myopia ranging from −3.0 to 23.0 D and up to 6 D of astigmatism, with anterior chamber depth (ACD) of 2.8 mm and a stable refraction within 0.5 D for 1 year prior to implantation. It is contraindicated in patients with ocular comorbidity that includes corneal degeneration or dystrophy, low endothelial count, lens opacity, pseudoexfoliation, pigment dispersion, glaucoma, intraocular inflammation, macular pathology, and neovascularization. A limited BCVA can sometimes be a contraindication to ICL surgery as it is argued that the visual gains are not justified against both the risk and cost of the procedures, as well as the results not reaching the patient’s expectations.

Bilateral ICL surgery was carried out successfully for this patient with UCVA of 6/7.5- in both eyes. The left eye remained stable. During the fourth month the patient presented as an emergency due to a sudden drop in visual acuity in the right eye. There were no reports of trauma of any other conditions. The following refraction was found:

RE UCVA 6/15-           0.00/-1.75×90              6/7.5-

LE UCVA 6/7.5-          N/A

Dilation of pupil showed that the ICL had rotated by approximately 40 degrees. The patient was put forward for a reposition, which was carried out successfully under topical anaesthesia. The following day there was a notable improved in UCVA reaching 6/7.5- once again. This has remained stable since.

Toric ICLs generally provide excellent vision and have been shown stability even after severe intense trauma [3]. One study found that that ICL dislocation occurred in the dark where pupil dilation could play a role in the movement of the ICL [4]. Another hypothetical cause of rotation suggested by Navas et al is that a haptic of the toric ICL could have remained slightly folded and after mechanical trauma became unfolded and changed the alignment [5]. But in this case, as there was no trauma reported, this in unlikely to have been the case. The surgical team have classified this as a spontaneous ICL rotation.

ICL implantation is considered a safe and effective alternative to laser eye surgery for high myopes and has a high rate of satisfaction [6] amongst those who have undergone the procedure. ICL rotation is extremely rare and easily solved with a reposition of the lens.

References:

[1] Sachdev, G. S., & Sachdev, M. (2017). Recent advances in corneal collagen cross-linking. Indian journal of ophthalmology, 65(9), 787–796. doi:10.4103/ijo.IJO_648_17

[2] Derakhshan, A., Shandiz, J. H., Ahadi, M., Daneshvar, R., & Esmaily, H. (2011). Short-term Outcomes of Collagen Crosslinking for Early Keratoconus. Journal of ophthalmic & vision research, 6(3), 155–159.

[3] McCauley MB, Anderson DM, Johnson AJ. Posterior chamber visian implantable collamer lens: stability and evaluation following traumatic grenade explosion. J Refract Surg. 2008;24:648–651.

[4] Kong J, Qin XJ, Li XY, et al. Implantable collamer lens dislocation. Ophthalmology. 2010;117:399.e1

[5] Navas, A., Muñoz-Ocampo, M., Graue-Hernández, E. O., Gómez-Bastar, A., & Ramirez-Luquín, T. (2010). Spontaneous Rotation of a Toric Implantable Collamer Lens. Case reports in ophthalmology, 1(2), 99–104.

[6] Packer M. (2016). Meta-analysis and review: effectiveness, safety, and central port design of the intraocular collamer lens. Clinical ophthalmology (Auckland, N.Z.), 10, 1059–1077.

One of the benefits of being a part of our optometrist network is that we provide and host in-house training to all members of your practice who require knowledge and information on refractive surgery. We tailor the sessions to the attendees and will include more or less clinical and technical information depending on the existing levels of knowledge of attendees. Our specialist optometrists are available to provide extra clinical training if required and are available to discuss pre-operative criteria and aftercare in more depth for any optometrists who attend the sessions. Recently we carried out some training for one of our partner opticians Eyesite Weybridge.

A training day usually consists of:

• A tour of our Harley Street clinic
• The opportunity to watch laser surgery through our transparent laser theatre suite
• Lunch at a lovely restaurant in Marylebone
• A thorough explanation and demonstration of our state-of-the-art diagnostic equipment and the opportunity to carry scans on each other
• A Q&A session with our lead surgeon and medical director, Mr CT Pillai (clinic-permitting)

If you are interested in visiting our clinic and booking your staff in for onsite training please get in touch with our Business Development Manager Ryan Acana on 07738 059 501 or ryan@advancedvisioncare.co.uk

It was an absolute pleasure having this lovely group spend the day with us here at Advanced Vision Care; we hope you enjoyed your experience!

In 2010, patient IK, a doctor in the public health sector attended our clinic enquiring about vision correction surgery. He had a history of strabismus and had undergone squint surgery as a child. His prescription was unmanageable, and he was struggling with both glasses and contact lenses. Refraction found:

Such a prescription had never been treated with ICL implantation in the UK. Hyperopic patients tend to have low Anterior Chamber Depths (ACD) therefore less space, and that combined with a slightly thicker ICL can lead to potential post-operative problems. Luckily this patient had sufficient space in the anterior chamber and our expert surgical team were able to carry out successful and uneventful bilateral ICL surgery for him. This was 19 years ago; to this day he is still satisfied with his vision! ICL designs have come a long way since then and are continuing to evolve and to establish a firmer place in the market as an alternative to laser eye surgery.

• Read our article on the Dailymail
• Read what the patient had to say